# Knee and Lower-Limb History

Date: Tuesday 15 September 2026

Last Updated: Friday 11 September 2026

Type: Letter

## Summary

This document provides a structured chronological history of the patient's knee and lower-limb symptoms from September 2025 to September 2026.

The history includes symptoms affecting both knees, lower-limb alignment, calf heaviness, mobility and activity limitations, physiotherapy, exercise programmes, and subsequent musculoskeletal assessment.

It also records an acute low-back-pain episode where the possible relationship to the pre-existing lower-limb problem was raised during later clinical discussion.

This document records the patient's reported history, available healthcare records, and known dates. It does not attempt to provide a diagnosis or establish that events occurring close together had the same cause.

## Background

### Purpose

This document aims to preserve the chronological development of the knee and lower-limb problem, including:

- the onset and progression of symptoms affecting both knees;
- lower-limb and calf observations;
- effects on walking, standing, stairs, squatting, and kneeling;
- physiotherapy, exercise programmes, and treatment responses;
- relevant GP, First Contact Practitioner, and musculoskeletal-service contacts;
- the acute low-back-pain episode where a possible relationship to the lower-limb problem was later raised;
- whether dates and details are confirmed.

Detailed records concerning the acute low-back-pain episode, the right-hand wound and skin changes, the suspected medicine reaction, and the July 2026 thirst-related episode are maintained separately.

Where those events overlap with the knee and lower-limb history, this document preserves only the information required to understand the chronology and possible clinical relevance.

The document does not present the patient's observations as a diagnosis. Where a date, clinical finding, treatment detail, or suspected physical change cannot be confirmed, this is stated clearly.

### Date labels

- **Confirmed date** – supported by an available record, appointment information, prescription label, or contemporaneous document.
- **Approximate date** – based on the patient's recollection.
- **Date to be confirmed** – cannot currently be established reliably.

## Details

### Childhood – previous falls directly onto the knees (Approximate)

- The patient recalls several childhood falls in which the knees struck the ground first.
- At approximately two to three years of age:
  - the patient fell forwards while going down stairs;
  - one knee struck the ground first;
  - the affected side can no longer be recalled;
  - the knee sustained a superficial wound that required an adhesive plaster.
- Before the age of twelve, the patient recalls approximately three further falls at school:
  - all involved falling forwards and landing directly on one or both knees;
  - on at least one occasion, both knees struck the ground;
  - on one occasion, the right knee struck the ground;
  - for the remaining occasion, the patient cannot recall whether one or both knees were affected.
- The knee wounds were managed with basic first aid, recalled as including an antiseptic solution such as yellow antiseptic liquid.
- None of these events resulted in medical assessment.
- Each episode appeared to recover within approximately one to two weeks.
- The patient did not identify a definite persistent knee problem following these events at the time.
- It is not known whether these childhood falls have any relevance to the knee and lower-limb symptoms that became apparent in 2025.
- This history is recorded as background only and does not establish that the current symptoms resulted from previous injury.

### Around mid-September 2025 (Approximate) – onset of right-knee symptoms

- Approximately one week before the GP consultation on 25 September 2025, the patient began experiencing intermittent pain in the lower part of the right knee when using stairs.
- During that week:
  - the pain occurred approximately two or three times;
  - the pain was mild;
  - it occurred occasionally rather than every time the patient used stairs.
- There was no known injury or trauma associated with the onset.
- The patient remained able to walk and carry out ordinary daily activities.
- As the problem continued, the patient also noticed:
  - occasional right-knee discomfort while walking;
  - a sense that the right lower limb or knee was unstable or did not feel normal;
  - reduced confidence when squatting or kneeling on the right knee.
- The patient generally avoided placing full body weight through the right knee while kneeling and therefore cannot confirm whether full weight-bearing in that position was possible without symptoms.

### Thursday 25 September 2025 – GP consultation and physiotherapy referral

- The patient consulted the GP and reported the recent right-knee pain.
- The patient was subsequently referred for physiotherapy regarding the right-knee problem.

### Monday 17 November 2025 – First physiotherapy appointment

- The patient attended the first recorded physiotherapy appointment.
- The physiotherapist performed an initial assessment and guided the patient through exercises.
- A weight-reduction programme was also started.
- A printed home-exercise programme was provided, with handwritten adjustments to the number of repetitions following assessment.
- The patient recalls being instructed to:
  - perform exercises twice daily, in the morning and evening;
  - complete approximately two exercises during each session;
  - perform approximately five repetitions of each exercise.
- Some exercises required a resistance band.
- The physiotherapist recommended obtaining:
  - a loop resistance band;
  - topical ibuprofen gel, such as Ibuleve.
- The patient subsequently obtained an approximately 12-inch loop resistance band and began following the prescribed exercise programme.

### Around Monday 24 November 2025 (Approximate) – first use of Ibuleve, exercise-related sensation, and subsequent symptom change

- Approximately seven to ten days after the first physiotherapy appointment on 17 November 2025, the patient used Ibuleve gel around the right knee for the first time.
- The physiotherapist had recommended the topical gel, but the patient had not been able to obtain it on the day of the appointment.
- The exact date can no longer be confirmed.
- Based on the remembered interval after 17 November 2025, the event is estimated to have occurred around 24 November 2025.

During that session:

- the patient completed some of the prescribed exercises;
- Ibuleve gel was applied around the right knee;
- the patient understood that the gel had been suggested partly to provide a cooling or soothing effect;
- after applying the gel, the patient did not notice a substantial immediate sensation or obvious change;
- because there was little noticeable effect, the patient performed some further exercises.

During the later exercises:

- the patient noticed a mild, unfamiliar aching or weak sensation around the inner aspect of the right knee;
- the sensation was not described as severe pain;
- the patient stopped the exercise after noticing it;
- there was no recognised injury, obvious displacement, or immediate awareness that the kneecap or another structure had changed position.

Over approximately the following one to two weeks:

- the patient noticed that the mild right-knee pain previously experienced when using stairs had not recurred;
- the earlier stair-related pain had been present intermittently since September 2025;
- only after noticing its continued absence did the patient reconsider the unusual sensation experienced during the exercise session;
- the patient retrospectively wondered whether the kneecap or another part of the knee may have changed position during the exercise.

By the time this possibility was considered:

- the precise exercise movement could no longer be recalled;
- the exact date could no longer be confirmed;
- there had been no clinical examination or imaging confirming a structural change.

This record therefore preserves the sequence of:

- first using Ibuleve;
- performing further exercises;
- noticing an unfamiliar aching or weak sensation;
- stopping the exercise; and
- subsequently noticing that the earlier stair-related pain had stopped.

The timing does not establish whether the improvement resulted from the exercises, the gel, a change within the knee, the wider physiotherapy programme, or another reason.

### September 2025 to February 2026 – ALT result, ketogenic-style diet, weight reduction, and increasingly noticeable bilateral calf heaviness

- A blood sample taken on **24 September 2025** later showed **ALT 57**.
- The patient became aware of the result around late September / early October 2025.
- After receiving advice to reduce weight, the patient gradually moved towards a ketogenic-style diet and had broadly implemented it by approximately early October 2025.
- The diet was not based on prospective calorie, macronutrient, or portion calculations.
- Meals were generally prepared from foods such as meat, vegetables, and avocado.
- The patient usually ate according to appetite, commonly around two meals per day, stopping when feeling full or no longer wishing to eat and keeping remaining food for a later meal.
- No intermittent-fasting schedule such as 16:8 was intentionally followed.
- Any estimate of energy deficit was made retrospectively rather than from contemporaneous daily tracking. The later estimate suggested an average deficit of approximately **1,000 kcal per day**, but this should be treated as approximate.
- Body weight was approximately **94 kg** around the beginning of this period and approximately **86 kg** by February 2026.
- These measurements were taken on different scales / at different locations and should therefore be treated as approximate.
- Clothing became clearly looser, particularly around the waist and thighs.
- A later blood sample taken on **26 January 2026** showed **ALT 21**.

Despite the overall reduction in body weight:

- both calves felt subjectively heavier rather than lighter;
- the heaviness was broadly bilateral and similar on both sides;
- the sensation was present generally rather than only on stairs;
- during walking, the patient felt that greater effort was needed to lift the legs compared with before;
- there was no associated calf pain, cramping, swelling, numbness, increased warmth, or skin-colour change.

The patient found this contrast unusual because the whole body had become lighter, while the perceived load or heaviness in both calves had increased compared with around September / October 2025.

This contrast was one reason the calf symptoms were later raised during FCP / MSK assessment.

Around late February 2026, after antibiotic treatment began for the right-hand problem, the patient noticed a strong increase in desire for carbohydrate-containing foods and was unable to continue the ketogenic-style diet despite attempts to do so.

After stopping the ketogenic-style diet:

- body weight remained broadly stable;
- the bilateral calf heaviness also remained at approximately the same level rather than clearly resolving.

This record preserves the nutritional, weight, laboratory, and symptom chronology. It does not establish that the ketogenic-style diet, energy deficit, weight reduction, ALT changes, antibiotic treatment, or later dietary change caused the calf symptoms.

### Monday 9 February 2026 – First Contact Practitioner assessment and MSK referral

- The patient attended a First Contact Practitioner assessment.
- The patient explained that:
  - overall body weight had decreased by approximately 8 kg;
  - clothing had become noticeably looser;
  - but both calves felt heavier rather than lighter, particularly when using stairs.
- The patient explained that, because the whole body had become lighter, the lower limbs might reasonably have been expected to feel less heavily loaded, whereas the opposite appeared to have occurred.
- The patient recalls that the clinician agreed that this expectation was understandable.

The FCP record documented:

- intermittent pain at the front of the knees, with the right knee more affected than the left;
- occasional clicking;
- symptoms aggravated by going up and down stairs;
- a feeling that the right knee might give way;
- no identified injury or trauma associated with the onset in September 2025;
- pain recorded as 2 out of 10;
- no effect on sleep;
- no analgesia being used at that time.

The recorded clinical impression was **“bilateral anterior mechanical knee pain, right greater than left,”** meaning activity-related pain at the front of both knees, with the right knee more affected than the left.

The objective assessment recorded:

- no knee swelling or increased warmth;
- mild lateral deviation of the patella;
- no pain on palpation around the knee;
- ability to stand from sitting;
- mild anterior knee pain during squatting;
- full knee flexion and extension without recorded crepitus;
- broadly equal muscle strength on both sides, recorded as 4+;
- no laxity on anterior drawer, posterior drawer, valgus, or varus stress testing;
- anterior patellar discomfort during the Clarke test;
- mild observed quadriceps weakness during resisted testing.

The FCP record also described outward alignment involving the right knee and calf or lower limb.

- After reviewing the record, the patient compared both lower limbs more carefully and noticed a continuing outward appearance or alignment of the right calf and lower limb.
- This perceived difference has remained present up to the date of this document.
- The patient cannot determine whether this represents an anatomical difference, a postural or movement-related change, or another cause.

The clinician discussed referral for further musculoskeletal assessment, and the patient agreed to proceed.

The original FCP assessment and referral record should remain the primary source for the exact clinical terminology and findings.

### Friday 13 to Sunday 15 February 2026 – new left-knee symptoms over approximately three days

- Around 13 February 2026, the patient developed a new symptom affecting the left knee.
- This felt different from the previous right-knee symptoms.
- It was triggered when:
  - squatting;
  - bending down;
  - bringing the thigh close to the calf.
- The precise triggering position was difficult to describe and could be demonstrated more clearly in person.

The pain was:

- sudden;
- substantially stronger than the earlier right-knee pain;
- brief;
- severe enough to require the patient to stop the movement and sit down immediately.

When the symptom occurred:

- the patient could not maintain the triggering position;
- there was also a very brief sensation described as numbness, tingling, or weakness in the leg;
- this sensation lasted approximately one second and resolved after sitting down.

The episodes occurred approximately three times over three days.

During this period:

- squatting and bending down were significantly affected;
- prolonged walking or standing also became difficult because symptoms could require the patient to stop and sit down.

These symptoms occurred several days before the later onset of low-back pain. Their timing is recorded without assuming that the two problems had the same cause.

### Around Friday 20 to Sunday 22 February 2026 – progression from intermittent low-back discomfort to severe pain

- Before approximately 20 February 2026, the patient had already noticed occasional discomfort or pain in the lower back.
- These earlier episodes were limited and not considered particularly concerning because they occurred only once or twice and remained manageable.
- Around 20 February 2026, the low-back problem became more noticeable and began occurring more consistently.
- The pain was centred in the lumbar region, immediately above the hips.
- The exact date on which the symptoms changed from occasional to more persistent cannot now be confirmed.

During movements such as squatting, bending down, or changing position:

- the patient found it necessary to keep the back relatively straight;
- moving in another way appeared to aggravate the pain;
- this further affected movements that had already become difficult during the recent left-knee symptoms.

On Sunday 22 February 2026:

- the low-back pain remained present and became increasingly troublesome;
- from approximately 10:00 pm, the pain became substantially more severe and continued at that increased level;
- the patient found it extremely difficult to rest or find a comfortable position;
- the continuing pain prevented the patient from falling asleep.

This section records a progression from earlier occasional and manageable symptoms to a more persistent problem around 20 February, followed by marked and continuing worsening from approximately 10:00 pm on 22 February.

It does not establish whether the low-back pain was caused by, or shared the same cause as, the preceding knee and lower-limb symptoms.

### Early morning, Monday 23 February 2026 – persistent symptoms and decision to seek urgent medical care

- By the following morning, the low-back pain remained severe.
- The patient was exhausted after being unable to sleep properly during the night.
- A pre-existing wound on the back of the right hand also remained itchy and symptomatic.
- The combination of severe low-back pain, lack of sleep, and the unresolved hand wound had become difficult to manage.
- The patient therefore decided to seek urgent medical assessment rather than wait for a pre-booked GP appointment.

### Monday 23 February 2026 – MIU attendance and onward travel to UTC

- The patient first attended a Minor Injuries Unit.
- According to the patient's recollection, the MIU did not provide treatment for either the severe low-back pain or the right-hand wound.
- The patient was advised to obtain an over-the-counter product from a pharmacy.
- The patient did not consider this sufficient because:
  - the low-back pain remained severe;
  - the pain had prevented adequate sleep;
  - the hand wound remained unresolved and symptomatic.
- The patient therefore travelled to an Urgent Treatment Centre for further assessment and treatment.

### Monday 23 February 2026 – pain changes observed in the hospital car-park lift before UTC assessment

- After arriving at the hospital car park and before the UTC assessment, the patient travelled in a lift.
- Persistent baseline low-back pain was already present while the lift was stationary.
- The patient noticed that:
  - when the lift changed from stationary to moving, the pain increased at the same time;
  - while the lift remained in sustained motion, the increased pain continued;
  - when the lift slowed and stopped, the pain returned to its previous baseline level.
- The patient perceived the timing relationship as immediate.
- The original account referred more generally to increased pain during lift acceleration or deceleration.
- The later, more detailed recollection distinguished between:
  - the transition from stationary to moving;
  - sustained movement;
  - slowing and stopping.
- Lift speed, acceleration, force, and time intervals were not measured.
- The complete account and schematic diagram are preserved in the separate **Lift Movement and Pain Synchronisation Record**.
- This observation does not establish a physiological mechanism or diagnosis.

### Monday 23 February 2026 – UTC assessment, prescribed medicines, and continuing pain

- The patient attended the UTC seeking assessment and treatment for:
  - severe low-back pain;
  - the symptomatic right-hand wound.
- UTC prescription labels were dated 23 February 2026.

The medicines supplied were:

- **Flucloxacillin 500 mg**:
  - 28 capsules supplied;
  - label instructions: take one capsule four times daily.
- **Naproxen 500 mg**:
  - 28 tablets supplied;
  - label instructions: take one tablet twice daily.
- **Omeprazole 20 mg**:
  - 28 capsules supplied;
  - label instructions: take one capsule once daily.

- Flucloxacillin was prescribed for the symptomatic right-hand wound.
- Naproxen and omeprazole were supplied while the severe low-back pain was also being assessed.
- A further 56 flucloxacillin capsules were supplied at the GP follow-up on 27 February 2026.
- Full wound-treatment details are recorded separately in the **Recurrent Hand Skin Changes and Suspected Naproxen Medicine Reaction Record**.

### Wednesday 4 March 2026 – GP follow-up and discussion of lower-limb symptoms

- During the GP follow-up on **Wednesday 4 March 2026**, the patient asked whether it would be appropriate to seek osteopathic treatment for the pre-existing right-knee and lower-limb problem.
- According to the patient's recollection, the GP advised against seeking osteopathic treatment at that stage.
- The patient recalls the GP indicating that the recent acute low-back pain and the pre-existing right lower-limb problem might be related.
- The patient was advised to continue waiting for the musculoskeletal assessment.
- This recalled discussion did not establish a confirmed causal relationship between the low-back pain and the knee or lower-limb symptoms.

### Thursday 2 July 2026 – Musculoskeletal Services community appointment

- The patient attended a **Musculoskeletal Services community appointment** concerning the continuing knee and lower-limb symptoms.
- The patient brought:
  - a self-prepared wider musculoskeletal timeline;
  - the separate **Lift Movement and Pain Synchronisation Record**.
- The documents were reviewed as background information during the appointment and remained with the patient afterwards.
- Several staff members were involved, but the patient was not told the precise professional role of each person.
- One member of staff identified themselves as a physiotherapist, and a rehabilitation staff member later provided exercise instruction.

Matters raised included:

- the continuing right-knee and lower-limb symptoms;
- the earlier left-knee symptoms;
- perceived differences involving the knees, lower limbs, calves, and feet;
- altered sensation on the top of the right foot when using stairs;
- whether the February 2026 acute low-back-pain episode might be related to the longer-standing knee problem;
- the appropriate rehabilitation and loading plan;
- returning to stairs, kneeling, squatting, running, or other higher-load activities.

- The knee was examined during the appointment, including movement and functional assessment.
- According to the patient's recollection, the clinician considered that the acute low-back-pain episode was unlikely to be related to the knee problem.
- A rehabilitation staff member demonstrated two additional leg exercises.
- The patient was instructed to complete the two new exercises together with two existing physiotherapy exercises:
  - every other day;
  - two sets of five repetitions for each exercise.
- The effectiveness of the revised exercise programme was not yet known when this record was prepared.

### By Thursday 6 August 2026 – revised exercise frequency and current position

- The overall knee and lower-limb symptoms had not changed substantially.
- The patient continued the Musculoskeletal Services exercise programme.
- By 6 August 2026, the exercises were being completed approximately twice per week.
- The date on which the exercise frequency was reduced cannot currently be confirmed.
- No date has therefore been added for the change in frequency.
- The patient wishes to preserve the timing of musculoskeletal events so that any possible relationship with later symptoms can be reviewed retrospectively.
- At this stage, the record does not assume that the exercise programme caused or triggered any other health problem.

### Date to be confirmed – single right-knee mechanical click

- On one occasion, while in the kitchen, the patient stepped sideways to the right with the right leg.
- A single mechanical click was heard from the right knee.
- There was no pain, leg weakness, loss of balance, or fall.
- The patient was already moving cautiously and did not notice any immediate abnormality afterwards.
- The event occurred once only.
- No clear functional change has been noticed since.
- The event did not occur during an MSK exercise session and was not considered temporally related to exercise that day.
- The exact date cannot currently be confirmed.

### Thursday 3 September 2026 – further MSK assessment and rehabilitation plan

- The patient attended a further MSK assessment concerning the continuing lower-limb problem.
- The clinician performed a range of physical and functional tests.
- The patient recalls that most of the difficulty during testing appeared to be related to inability to complete the movement rather than pain.
- One test performed while lying on the examination bed did produce pain around the knee.
- The detailed clinical findings are expected to be recorded in the MSK assessment record and should remain the primary source for the examination findings.
- At the time this patient-prepared version was reviewed, the patient had not located a copy of the detailed 3 September MSK / Dynamic Health assessment record in the NHS App. This does not establish whether a separate provider record exists.
- Following the assessment, the patient was advised that they would be placed on a waiting list for one-to-one gym-based rehabilitation at the hospital.
- This document does not attempt to identify which specific muscle groups may be involved.

## Questions / Requests

The patient would appreciate ongoing assessment and advice regarding:

- the continuing knee and lower-limb symptoms;
- whether the revised exercise programme remains appropriate;
- whether the exercise programme should be adjusted if symptoms change or progress remains limited;
- the significance of the **continuing outward alignment or appearance of the right calf and lower limb**, together with the perceived instability, asymmetry, calf heaviness, and altered sensation affecting the top of the right foot;
- when activities such as stairs, kneeling, squatting, running, or other higher-load movements may be resumed more confidently;
- whether any further investigation or specialist assessment is required.

The patient can demonstrate the relevant body areas, movements, and triggering positions more clearly in person than in writing.

## Notes

### Supporting records

- Original NHS First Contact Practitioner assessment dated **9 February 2026**.
- Physiotherapy home-exercise sheet and related handwritten instructions.
- Musculoskeletal Services handwritten assessment and exercise notes dated **2 July 2026**.
- Self-prepared wider musculoskeletal timeline reviewed during the 2 July appointment.
- Separate **Lift Movement and Pain Synchronisation Record**.
- UTC and GP records concerning the February 2026 acute low-back-pain episode, where relevant.
- Photographs, medicine labels, and other original records where relevant and available.

This document provides a chronological history of the knee and lower-limb problem.

It does not replace the original clinical records and should be interpreted together with the patient's history, examination findings, and any available healthcare documentation.